Diagnosis

Because human papillomavirus (HPV) infections often cause no symptoms in men or women and are hard to identify, you must see a health care professional for diagnosis.

Genital warts are the least common problem caused by HPV infection. They can be flesh-colored and hidden inside the cervix, vagina, penis, scrotum or anus. They can be small or large, alone or in clusters, flat or round. They can spread along the groin or thigh or be found in the mouth.

Genital warts are a visible change caused by HPV. They can be seen with the naked eye and are on the surface of the skin.

The more common change from HPV are lesions of the cervix that are not visible to the naked eye and are detected through screening with Pap and HPV testing. These changes, called squamous intraepithelial lesions, are not visible to the naked eye and are only visible after vinegar has been applied to the cervix and the clinician looks through a microscope. This is called colposcopy. The screening by Pap and HPV tests identifies women who may have these lesions and need a closer look at the cervix through the colposcope.

Specific HPV types cause genital warts, known as condyloma acuminata. Each HPV type has been numbered and divided into high-risk or low-risk categories depending on whether the virus is associated with the development of cancer.

For example, HPV types 6 and 11, which are usually associated with genital warts, are considered low-risk. HPV types 16, 18, 31, 33, 45, 52 and 58, found on the genitals and in the anus, have been linked to most HPV-related cancers in both men and women and are therefore considered high-risk.

If you notice warts, see your health care professional. You should also seek an examination if:

  • You see any unusual growths, bumps or skin changes on or near the penis, vagina, vulva or anus.
  • You see any raised growth on the genital skin that is red, white or darkly pigmented as that could be precancer and should be evaluated by your health care professional.
  • You experience unusual itching, pain or bleeding in the genital or anal area.
  • You have a sexual partner who tells you that he or she has genital HPV or genital warts.

Sexual history does not determine the need or frequency for screening by Pap and HPV testing. Established guidelines apply to all women regardless of sexual history.

All women should have cervical cancer screening, according to guidelines. The Pap test is a simple procedure. For a Pap test, a health care professional uses a special brush and/or spatula to collect cells from the cervix and places them on a glass slide or in a liquid preservative, which is then sent to a laboratory for evaluation. When the sample is sent in the liquid vial, the remaining liquid can be tested for 14 types of HPV, using one of five FDA-approved HPV tests.

There is also an anal Pap test that is much like the Pap test for cervical cancer. It involves swabbing the anal lining and looking at the swabbed cells under a microscope. The anal Pap test is relatively new and hasn't been studied well enough to determine when, how often and on whom it should be performed, or if it actually reduces risk of anal cancer. Some experts recommend it be done regularly in men who have sex with men.

There are different classifications for abnormal results for the cervical Pap test, but the most common is called atypical squamous cells of undetermined significance (ASC-US). This is a borderline abnormal category and most women with this Pap result do not have abnormal cells. In women ages 21 to 24, a repeat Pap is ordered 12 months later. In women ages 25 to 65, an HPV test will be done to determine whether colposcopy is required or whether a woman needs a follow-up Pap and HPV test in three years. Women with an ASC-US Pap and a positive test for high-risk HPV types will require a closer look at the cervix with the microscope.

Routine follow-up after a negative Pap and HPV is five years.

The other abnormal Pap categories include low-grade (mild) change and high-grade (moderate to severe) change, which is considered precancer.

In conjunction with the Pap test, which screens for abnormal cells once cell changes have taken place, there are tests that look specifically for HPV. These tests can detect the presence of HPV in the cells, which may allow for the detection of abnormal cells that were missed by the Pap and also identifies women with future risk who need to be followed closely as long as the virus persists. There are currently five FDA-approved HPV tests. All but one is able to report the presence or absence of a panel of 12 types of HPV and can genotype specifically for HPV 16 and 18, which cause the majority of cervical cancer. Guidelines for screening and management are different in some cases when HPV 16 or 18 is present.

At this point, HPV tests are also FDA-approved for reflex testing for women whose Pap test reveals ASC-US (borderline abnormal) cells, to determine the need for colposcopy in women who are HPV positive and for cervical cancer screening in combination with a Pap test in women over age 30.

Two tests that report HPV 16 and 18 on every test are now approved for primary HPV testing, which may mean your health care professional will order only an HPV test and not a Pap test initially. If a Pap test result is abnormal, then a colposcopy is recommended. If a Pap test result is not abnormal then an HPV test is repeated in one year. If the HPV test is negative, it is repeated in three years, according to published guidance. In 2018, the U.S. Preventative Services Task Force recommended HPV stand-alone testing with a repeat if negative in five years.

There are currently no recommended screenings or FDA-approved tests that detect HPV infection in men, but research is continuing.

Along with medical history and evaluation of other risk factors, the HPV test helps health care professionals determine what follow-up might be necessary if there is an abnormal result from a Pap test. When a Pap test is high-grade abnormal, the HPV test doesn't alter the virus management, which is a look at the cervix through the colposcope.

Pap Test Screening Guidelines for Women

The American Cancer Society, the American College of Obstetricians and Gynecologists and the U.S. Preventive Services Task Force recommend the following guidelines for Pap tests and early detection of cervical cancer:

  • All women should begin screening at age 21.
  • Women ages 21 to 24 should have a Pap test every three years. They should not have an HPV test. If an HPV test is done in the lab and is positive, it doesn't change the management of borderline and mild abnormal Pap tests. The Pap is repeated in 12 months. High-grade abnormal Pap tests require colposcopy.
  • Women ages 25 to 29 should have a Pap test every three years. If the Pap is borderline abnormal (ASC-US), then an HPV test is used to determine whether that woman should have colposcopy or a three-year follow-up. ASC-US with positive HPV test result requires a colposcopy.
  • Women ages 30 to 65 should have both a Pap test and an HPV test every five years, a Pap test alone every three years or an HPV test alone every three or five years. (The organizations have some variances in preference for type of tests and frequency; talk with your health care professional about what's best for you.)
  • Women over age 65 who have been screened previously with normal results in the previous 10 years (three Pap tests or two Pap and one HPV tests with no abnormal results) should stop getting screened. Women with cervical precancer should continue to be screened until they have completed 20 years of follow-up.
  • Women who have had a total hysterectomy, with removal of their uterus and cervix, and have no history of cervical cancer or precancer should not be screened. Many women who have had a hysterectomy do not know if they still have their cervix. It should not be assumed that the cervix was removed along with the body of the uterus. If the cervix was left behind, screening should continue according to guidelines.
  • Women who have received the HPV vaccine should still follow the screening guidelines for their age group.
  • Women in special populations including HIV positive, immunosupressed, and DES-exposed are not included in the guidelines for the general population.

If your health care professional identifies any unusual cell changes, he or she will recommend a plan of action, depending on the result and your health history. That may include, a repeat Pap test, an HPV test, or a colposcopy which is a more thorough examination and biopsy of any abnormal area. If the Pap reveals ASC-US and the HPV test is positive, a colposcopy will be the next step. A health care professional will also order a colposcopy if the Pap results signal any other more serious changes.

Further screening and treatments will depend on the results of the colposcopy. In most cases, mild dysplasia (CIN 1) will not be treated, but your health care professional will follow up according to guidelines based on the severity of the screening test. This may include co-testing with Pap and HPV after 12 months, or after 12 and 24 months with any abnormal Pap or positive HPV test leading to a repeat colposcopy. For CIN 2, CIN2,3 or CIN 3, further treatment will be needed to remove the abnormal cells. In young women, CIN 2 or 2,3 may be followed before treatment is done.

Regular age-related cervical cancer screening by Pap and HPV testing is equally important for lesbians and bisexual women who, studies find, may be less likely to seek routine health care because of the discomfort they feel discussing or revealing their sexual orientation to health care professionals. They also may not want to undergo screening because they feel they are not at risk. However, lesbian and bisexual women are also at risk for HPV infection and cervical cancer (for example, through prior male partners, vibrators and other sexual aids or skin-to-skin contact with an infected partner).

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